Provider Demographics
NPI:1942206024
Name:HEALTHTEXAS PROVIDER NETWORK
Entity Type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-860-8649
Mailing Address - Street 1:8080 N CENTRAL EXPY
Mailing Address - Street 2:STE 600, LB82
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1838
Mailing Address - Country:US
Mailing Address - Phone:972-860-8648
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:3409 WORTH ST
Practice Address - Street 2:SUITE 640
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2029
Practice Address - Country:US
Practice Address - Phone:214-826-6276
Practice Address - Fax:214-826-6223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00837T208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1550287-01Medicaid
TX1550287-01Medicaid